Note: There were no September or October issues.
By Richard D. Glasow, Ph.D.

If the RU 486/Cytotec prostaglandin (RU 486/PG) abortion technique goes on the U.S. market in 1999 or 2000 as planned, many of the high-volume “abortion mills” clustered in the major metro areas would very likely use it because they have the facilities and staffing to handle the extra requirements. But offering chemical abortions only in the big cities would not achieve the abortion advocates' goal of weaving abortion deeper into the fabric of the life of the nation by making it available virtually everywhere.

RU 486/PG supporters' plans depend on convincing significant numbers of non-abortionists such as general-practice and family-practice physicians to start using the new chemical technique. Dr. Carolyn Westhoff, an abortionist who participated in trials of several forms of chemical abortion, said “One of my real, and I think realistic, hopes for this method is that it will help get abortion back into the medical mainstream and out of this ghettoized place it's been,” reported the July 11, 1999 New York Times Magazine.

Surveys of physicians conducted in 1994, 1995, and 1998 indicated that recruiting new abortionists may be a realistic possibility (see the March-April 1998 The RU 486 Report). But other evidence suggests that interest in RU 486/PG significantly cools when the prospective abortionists learn about the additional obligations required. For example, abortion advocate Carol Joffe described the reaction of a prospective abortionist in an article in the January/February, 1999 issue of Family Planning Perspectives, published by Planned Parenthood's research affiliate. One of the twenty-five abortionists whom she interviewed described his conversation with an internist “who runs a program with lots of internists and family practice doctors” and had incorrectly “believed it's a pill that you give and the patient goes home and has the abortion and that's it.” The internist was interested in doing chemical abortions until he “heard what was involved,” explained the abortionist.

Recent media articles and speeches at a conference in March, 1999 aimed at recruiting chemical abortionists indicate that abortion advocates are focusing special attention on trying to reduce—or even eliminate—two requirements that are major obstacles to recruiting.

First, under the current protocol, women must ingest the Cytotec prostaglandin at the abortionist's office and wait there four hours. About 50-to-60 percent of them abort there. This arrangement forces the abortionist to add extra staff and office space and disrupts the patient flow through the office. In view of this, the Population Council, the organization making the application for marketing to the U.S. Food and Drug Administration (FDA), may try to simplify the procedure for administrating the Cytotec prostaglandin by allowing the pregnant woman to ingest it at home. This change in protocol would eliminate one of the woman's three required visits to the abortionist, which might allay the concern that abortion supporters have quietly voiced among themselves that women will not comply with the lengthy and complicated regimen.

The second major obstacle is the requirement that the abortionist provide a surgical backup to treat the 5-to-10 percent of women who either have an incomplete abortion or no reaction at all to the drugs. In response, RU 486/PG advocates are encouraging family-practice and general-practice physicians to either learn how to perform a

simplified version of surgical abortion called manual vacuum aspiration (MVA) or arrange for an nearby obstetrician/gynecologist or surgeon to handle such cases. Promotion of MVA is part of a revival of interest in it among surgical abortionists as a quieter and less invasive form of abortion on women who are 6-to-8-weeks pregnant.

Pro-Family and Pro-Life advocates should be watching these developments closely for two reasons.

First, the Population Council is likely to ask permission from the FDA to permit women to take the Cytotec prostaglandin at home. Since the FDA controls approval for the final protocol on how RU 486/PG is administered, the decision on Cytotec will be handled at a federal level. When President Clinton took office in 1993, FDA officials blatantly jettisoned the agency's traditional scientific and medical objectivity and actively promoted marketing of RU 486/PG. The FDA may approve women taking Cytotec at home despite the fact that the procedure was not part of the U.S. and French tests, was not considered by the FDA's Advisory Committee in 1996, and will put women's health and lives in danger. The majority of women will abort at home without immediate access to emergency care for adverse side effects.

Second, in contrast to having to deal with a national decision on using Cytotec, the RU 486/PG advocates' plans for handling incomplete or “failed” abortion must be carried out at a local community level where the pro-family and pro-life networks are strongest. Local educational efforts reinforcing community and patient opposition to abortion in any form may prevent physicians from becoming involved either directly or indirectly with chemical abortion.

Taking Prostaglandin At Home

Possibly the biggest administrative obstacle confronting a physician who wants to offer RU 486/PG abortions is the extra cost and inconvenience of handling women who take Cytotec and wait in his or her office for the abortion to take place. Some abortionists see no reason why the women cannot take the Cytotec at home.

The safety and efficacy claims in the Population Council's application to the FDA in 1996 relied on the French and U.S. trials which included the requirement that pregnant woman ingest the prostaglandin Cytotec (trade name: misoprostol) in the abortionist's office 48 hours after RU 486. Then the woman waited there for 4 hours. (See the August, 1996 The RU 486 Report.)

Two groups of U.S. researchers have been working for over five years on how to use Cytotec at home. One group headed by Dr. Eric Schaff in Rochester, New York tested a “clone” of RU 486 with Cytotec on at least 2,700 women under the auspices of the Abortion Rights Mobilization (ARM) (See the April-May, 1999 The RU 486 Report). This research has allegedly demonstrated that women “can safety and reliably take the second drug at home” reported the August 4, 1999 USA Today. And the cover story of the July 11, 1999 New York Times Magazine described the procedure at Rochester in detail including how the pregnant woman “will find someplace private and comfortable to lie down—probably her own bed— and vaginally insert four tablets of a medication called misoprostol.” Since 1993, another group, with some of the same members as ARM's RU 486/PG researchers, tested the anti-cancer drug methotrexate with Cytotec prostaglandin (MTX/PG) including having the women insert the Cytotec vaginally at home.

“Not being able to use misoprostol at home is a barrier to entry to providing medical (chemical) abortion services,” asserted Dr. Suzanne Poppema, president of the National Abortion Federation, the trade association of abortionists, at a workshop in San Francisco on March 10, 1999. The session titled “Providing Medical Abortion Services” was specifically aimed at encouraging more physicians to perform chemical abortion by describing in detail how her office in Seattle has been offering several forms of chemical abortion since 1994, including RU 486/PG and MTX/PG. She explained that “Having a group of women doing a lot of bleeding and cramping in your office, when they would rather be home, racing to the bathroom when they need to go to the bathroom, because we were using oral misoprostol so they were not only having bleeding but they were also having diarrhea, doesn't do much for the [patient] flow in your clinic.”

Later in the workshop, the administrator of Poppema's abortion facility described some of the major renovations that an abortionist would need to make to an office in order to comply with the protocol, including adding more bathrooms. “If you only have one or two [bathrooms], that can be very difficult,” she observed. Also, women waiting for the abortion three or four hours and experiencing cramping “wanted someplace to do that individually.” Separate waiting rooms were preferable to a large open room, she said.

Based on her experience testing MTX/PG chemical abortion with the women inserting the Cytotec vaginally at home, Poppema believed “that there is no real medical reason that women have to be in a medical care system when they use misoprostol.” In fact, she said “What you do have to do is make sure that the woman is not alone, make sure that she has access to some emergency care if she needs it,” and has access to a telephone.

“My personal view about how we should do medical abortion is a one-stop abortion,” asserted Poppema. “You come in, get your counseling, decide what kind of abortion you are going to have, you have the medical (chemical) abortion and you get a little pregnancy test slide to take home. And in two weeks you pee on this slide, and you send it back to us, and if it's negative, you're done, and if it's positive, you need to come in. If it's positive, you still might not need to have anything, you still might be okay, but we need at least to make a contact.”

Dr. Poppema indicated that the Population Council is seeking authority from the FDA to have women take the Cytotec orally at home instead of the abortionist's office. The current protocol before the FDA is to use Cytotec 36-to-48 hours after RU 486 in the abortionist's office, Poppema stated. “We're trying to change it to at home, is all that we're trying to change,” she said. “Once you can do the misoprostol at home, then it becomes a very easy service to provide,” she observed.

Who Does the Surgery?

A second major stumbling block for the prospective abortionist to consider is the necessity to handle the inevitable cases where the drugs either cause a partial abortion or have no effect at all. In these estimated 5-to-10 percent of women, the abortionist must perform either a Dilation and Curettage (D&C) or a complete surgical abortion.

Many non-obstetrician/gynecologists who would otherwise be disposed on social or financial grounds to offer RU 486/PG might naturally be reticent to start doing these procedures because of medical considerations. They often have not received specialized training and do not perform such surgery regularly. Even the pro-abortion members of the U.S. Food and Drug Administration's hand-picked Advisory Committee that recommended approval of RU 486/PG for market in July 1996 expressed strong reservations about having general practitioners and family physicians routinely performing suction aspiration abortions.

Early Surgical Abortion

Doctors can offer pregnant women chemical abortion “without being capable of providing the whole array of surgical abortion services,” Poppema assured her audience. “You just need to learn how to use MVA, which does not take much longer [to learn] in terms of technique than spending whatever you spent learning endometrial biopsies and intrauterine devices,” she said.

MVA, or manual vacuum aspiration, is a surgical technique performed on women who are 6-to-8-weeks pregnant in which the abortionist uses a hand-held vacuum syringe with a replaceable cannula instead of a cannula attached to a hose connected to an electric suction machine. Until the last few years, “most doctors thought of MVA as a low-tech, Third World procedure,” reported Kim Painter in the August 4, 1999 USA Today.

Dr. F.P. Bailey, a professor at Tufts University School of Medicine, summarized the traditional arguments against MVA in a medical textbook Operative Obstetrics published in 1995. First, in the absence of a widely available accurate test to confirm early pregnancy, abortionists were performing MVA on women who might not be pregnant. Second, a “pregnancy is liable to be

missed during such a procedure.” Third, the “appropriate movement of instruments is almost impossible making retained tissue [incomplete abortion] more likely.” And fourth, “it is more painful than a later abortion.” In addition, Bailey noted that the MVA technique “is being performed and taught by members of the lay community to women's groups around the country” which raises concerns about safety and completeness of the procedure.

But in the last three years, Dr. Jerry Edwards of Planned Parenthood of Houston and Southeast Texas started a revival of MVA by combining it with the recently developed early pregnancy tests and transvaginal ultrasound, reported Painter. “Its main advantage was gentle suction: In most cases, tiny gestational sacs would come out intact and visible,” she said.

Among the most important advantages of MVA for Dr. Poppema is that is that “women love it because it doesn't make any noise.” She observed that “To a woman, since I have started doing this, the women all say `That is so much better than the last time you did it.'” Poppema has decided to use MVA for any abortion of 10-weeks or less.

The IPAS kits for performing MVA are not expensive at about $35 each, Poppema said. They can be cleaned with bleach and reused with a new cannula. She also advised using MVA to teach abortion to medical residents. And the abortionist can take an IPAS kit for an MVA abortion right into the hospital emergency room to handle women with incomplete abortion. Avoiding using an operating room saves thousands of dollars, she said. Another advantage was that “you don't make them wait until they're eight weeks” to have an abortion, she noted, and the procedure merely takes “seventy-five seconds.”

In an article promoting “Early Abortion: Update and Implications for Midwifery Practice” in the November/December, 1998 Journal of Nurse-Midwifery, Deborah Narrigan devoted a major section to MVA. (Narrigan served as a member of the FDA Advisory Committee in 1996 and voted in favor of marketing RU 486/PG) Her description of the method incorporates Edward's innovations and generally conforms to other clinical accounts

This “simple and brief” procedure aborts women during the first 6-to-8 weeks of pregnancy, stated Narrigan. “It begins with confirming pregnancy with [a] sensitive urine test for HCG followed by gestational dating using transvaginal ultrasound,” she wrote. After intravenous sedation, the abortionist inserts a “very thin (6-7 mm) rigid cannula through the undilated cervix,” which she contended “causes less pain than the standard vacuum aspiration.” This cannula is attached to a 50-milliliter syringe that has a one-way valve. The abortionist performs the suction abortion manually, which is one of the major departures from the standard method which uses a powerful electric vacuum machine. Another major change with MVA is that the pressure needed is much less than usual suction technique. The abortionist uses ultrasound again to verify a complete abortion, Narrigan said.

MVA is apparently becoming more widely used. Narrigan reported that one Planned Parenthood affiliate performed over 1,300 MVA from 1995 to 1996, and the medical director of Planned Parenthood of San Diego and Riverside County, California told Painter that 2,400 women “chose early surgery in the past year.” The National Abortion Federation, which represents 350 abortionists, listed 101 that offer “early surgical procedures,” reported Painter.

Arranging Surgical Referrals

Another way for a family-practice and general-practice abortionist to handle a woman needing surgery is to refer her to another physician. Dr. Poppema described two possible scenarios for the referral depending on whether the physician doing the surgery knows about the chemical abortion. The type of referral depends on the local community standards and the surgeon's attitude toward abortion, she said.

Under Poppema's first scenario, the prospective abortionist already had an arrangement in place for a “pro-choice specialist” to handle women who need a D&C for a miscarriage. Poppema suggested that the abortionist ask the specialist “would you please do them for medical [chemical] abortion as well?”

In the second circumstance, Poppema suggested using a subterfuge if the prospective abortionist is in a community that is strongly “anti-choice and you don't have supportive speciality providers.” Because a chemical abortion “looks exactly like a miscarriage – or if you are not supposed to be having sex at all—looks exactly like a heavy period,” she recommended that the abortionist refer the woman for treatment of a “miscarriage,” not abortion. Poppema emphasized that “The nice thing about medical [chemical] abortion is that it is indistinguishable in every single way from a spontaneous abortion.” In fact, she said, surgical intervention for chemical abortion “is absolutely in every way indistinguishable from caring for the complications of a spontaneous abortion.”

Obviously speaking tongue-in-cheek, Poppema assumed the role of the abortionist who had been asked by the surgeon about the rise in referrals for suction aspiration surgery for “miscarriages.” She said: “You just say `I don't know. Maybe we should do a study why there are more miscarriages in my practice all of a sudden.'” The audience laughed. “Nice of you to continue doing the suctions anyway,'” she continued.

In summary, the benefit of making referrals for surgery is that “you don't have to do them yourself,” Poppema concluded.

Conclusion

Abortion advocates have long asserted that marketing RU 486/PG will increase U.S. women's “access” to abortion services because more physicians would perform abortions in their private offices. Although some abortion zealots such as Eleanor Smeal seem confident about recruiting more physicians, there obviously is no guarantee that it is inevitable.

Now that RU 486/PG may be on the U.S. market soon, leading abortionists such as Dr. Suzanne Poppema are focusing attention on overcoming two major obstacles to convincing family-practice and general-practice physicians to become chemical abortionists: changing the protocol to use Cytotec at home and encouraging training in MVA or helping prospective abortionists to set up referrals for surgery for women after a “failed” or incomplete RU 486/PG abortion.

The issue of changing the protocol must be fought out at a national level because the FDA controls it. But local educational efforts to remind physicians of the community's and patient's opposition to abortion could prevent the spread of the dangerous chemical abortion method. Many obstetrician/gynecologists and most family practitioners who refuse to perform abortions for philosophical or moral reasons need continued support.

In the broad context, the same reasons that physicians have articulated for not performing surgical abortions also apply to RU 486/PG. One of the key ones is community and patient opposition and the fear of being known as an abortionist. Although most RU 486/PG abortions will require administering pills, it seems unlikely that a doctor will be able to hide the fact that he or she performs them. As reporter Carol Jouzaitis pointed out in the October 30, 1994, Orange County Register, “the logistics of accommodating women for several hours of medical observation would be daunting.” “It doesn't fit easily into a normal practice,” Jeannie Rosoff, the president of Planned Parenthood's special research affiliate, told Jouzaitis. “If you're a physician, do you want a group of women (having abortions) sitting for four hours in your waiting room with people who come in for colds and in-grown toenails,” Rosoff asked. The extra space and staff required might discourage some physicians.

In addition, pro-life and pro-family advocates should educate their local physicians about the professional drawbacks of using RU 486, especially the threat of medical liability lawsuits. Most are completely unaware of the extensive short-term dangers to the woman, which have been well documented. Also, the lack of long-term studies open physicians up to additional risk.

The potential liability is particularly severe in cases of continuing pregnancy. The RU 486/PG “drug cocktail” has no effect at all on about 1 out of 100 women. If such a woman does not return for all three visits and does not have a surgical abortion, she has a definite risk of having a deformed child. In Europe, as of July, 1996, twenty-one children have been carried to term after an attempted RU 486/PG abortion; three had abnormalities, one fatal. Family practice physicians and obstetrician/gynecologists need to realize that they might jeopardize their careers if they use RU 486/PG.

In summary, the responsibility for getting the truth out about RU 486/PG falls to the Pro-Life/Pro-Family Movement because no one else will do it. The information above provides an outline of the key points to stress to various audiences. Here is a final “sound-bite” of data that summarizes the key points:

“The Pro-life movement (or the name of your organization) strongly opposes the RU 486 abortion technique because it kills an unborn baby whose heart has started to beat, has already killed and injured women, can deform babies who survive the abortion attempt, may harm a woman's subsequent offspring, and will increase the number of abortions beyond the already appalling 1.5 million per year.